Search for tag: "pharmacy"

Dr. Chan: How does a pre-pharmacy major end up in medical school? What sparks an interest in something called PM&R? What happens when you and your spouse end up in the same rotation? How do you organize interviews for couples matching? Today on "Talking Admissions and Med Student Life" I interview James and Laura, fourth-year medical students here at the University of Utah School of Medicine.

Announcer: Helping you prepare for one of the most rewarding careers in the world, this is "Talking Admissions and Med Student Life" with your host, the Dean of Admissions at the University Utah School of Medicine, Dr. Benjamin Chan.

Dr. Chan: Well, welcome to another edition of "Talking Admissions and Med Student Life." I've got a couple in my office today. I'm so excited. Laura, James. Say hi.

Laura: Hi. Thanks for having us.

James: How's it going?

Dr. Chan: Great. Okay, so let's start the beginning. Both of you are from Utah.

Laura: Yes. I'm from Logan.

James: Yeah. And I'm from Taylorsville.

Dr. Chan: And where did you guys meet?

Laura: We met at Utah State.

James: Yeah, so we met in college. My next door neighbor was one of Laura's best friends. And so that's how we got introduced.

Dr. Chan: Okay, and what year is this about?

James: It was my sophomore year.

Laura: I think 2011.

James: Yeah, 2011.

Dr. Chan: Okay, love right away, love at first sight? Or was there some mental gymnastics that had to take place? Or how did it go?

James: Well, we dated for like eight months, and then we took a break and then we dated again for like another eight months. And then we got engaged. Does that sound about right?

Laura: Yeah. I met so . . .

Dr. Chan: Is that your version of reality, Laura? Or how do you feel about that?

Laura: Yeah, that's my version, I guess. James, so we met because . . . okay, my best friend actually was in love with James.

James: This is eight years ago, so . . .

Laura: This is the real story. So she was in love with James, and so she always wanted to hang out with him. And I was like trying to be a good wing woman and set them up. But James, I guess wasn't into her.

James: Well, I only have eyes for my neighbor's best friend. So after a few times hanging out, I got her number. I got Laura's number, I should say. And my neighbor, her friend was like distraught about it. And but actually Laura's parents, Laura asked her parents, "So should I go out with him or not? Because I don't think that my friend wants me to go out with him." And her dad was like, "Oh, you should definitely go out with him." And her mom was like, "No, you should be a good friend. You shouldn't go out with him. Because your friend . . ." Well, anyway, she followed her dad's advice.

Laura: I was a good friend, for the record.

James: You were a good friend.

Laura: And I said, "Hey, your crush asked me out. What do you think about this?" And she was like, "You should go out with him. It's fine. Nothing can get between us."

Dr. Chan: And then the friendship ended right there, Right?

Laura: And then the friendship ended right there.

Dr. Chan: She never talks to you again. She dropped the mic and walked away. All right. What year did you get married?

James: In 2013, yeah, 2013.

Dr. Chan: 2013. All right. And then at what point in your relationship did you both start thinking about med school? I mean, or did it predate getting together? I'm just curious how that kind of unfolded.

Laura: So James was always pre-med ever since I met him in 2011. And I was actually pre-pharmacy. And then after we broke up, actually, I was going through the committee process at Utah State, and everyone was like, "You are really competitive for med school, like have you considered going to med school?" And so then I kind of changed my mind at that point. And we were broken up.

James: Just to clarify. So the committee, the folks on the committee process at Utah State told her she had a stronger application than really any of the pre-meds. And she wasn't pre-med. So they were like, "Why aren't you going to medical school?" I mean, you hadn't really considered it seriously before then, right?

Laura: Yeah. So I started shadowing a pediatrician in Logan. And that's kind of when I realized it, it was what really was for me because it combined the patient care that I really liked with the medical decision making that I liked in the best way.

James: And bragging moment, she studied for the MCAT for just like 35 days and just like destroyed the MCAT. So anyway, I'm just throwing that out there.

Dr. Chan: Laura, for those of you who can't see at home, Laura is making faces.

Laura: Thank you.

Dr. Chan: All the secrets are coming out. Okay. All right. So I think this is fascinating, because then, like the first iteration of you applying together, what year was that?

Laura: Oh, gosh.

James: Oh, well, so we didn't apply together. It was 2000 . . . Let's see, we got married in '13. It was 2013. It was the '13-'14 academic year that you were applying to medical school. So you were applying to medical school right when we got engaged. And so she was in the midst of the application process at that time. I was not ready to apply. I hadn't taken physics yet. I hadn't done like my MCAT prep. And we didn't think I would have enough time to like give it a good go, yeah, catch up, really.

Laura: So what happened was I applied and got into the University of Utah, which is where I really wanted to go. And then James had to apply the next year when I was a first-year medical student.

Dr. Chan: And was that your strategy at the outset? Or did you kind of like broad net . . .? Because I don't know how many schools you applied to, but I get the sense the theme was you wanted to stay in Utah. Or were you willing to kind of be apart for a while? Or how did that look? Yeah.

Laura: Yeah, we knew that there was a chance that we would be apart for medical school. So that wasn't like a deal breaker for both of us going to medical school, but we thought Utah was kind of like our best chance.

James: Yeah. We definitely thought our odds were best in Utah. We were both Utah applicants. We kind of knew, you know, Utah it's pretty transparent about the things that you need to do, and we felt like we were meeting high marks on those things. And so when Laura got in, we were encouraged. And then we moved to Salt Lake City. I worked here for a year. I literally was just answering phones at one of the hospitals for a year while I was applying to med school, but I applied to a lot of schools knowing that Laura was already in medical school at the U. And I actually I got into like three other schools before I got into the University of Utah. So it was tenuous because I thought maybe I'd be moving to St. Louis or Pennsylvania, but then the call came in March.

Dr. Chan: Okay. I called you in March. I vaguely remember that.

James: It was a good day. It was a really good day.

Dr. Chan: All right. So you were separated by a year.

James: Mm-hmm.

Dr. Chan: Initially.

Laura: Yes.

James: Initially.

Dr. Chan: Okay. So how was that? I mean, like, you know, because like Laura's going through med school. She's kind of, you know, like the hard part about medical school in my view is that like people talk about it. There's definitely this image of what med school is like out in the media or like what people think culturally or stereotypically, but then you go to med school, and it's like hard to describe. That's one of the reasons why I do this podcast is just to kind of learn about it. So like, James, has Laura . . . or Laura, like, was it easy? Was it hard? I mean, how would you describe the jump from going, you know, from undergrad to medical school?

Laura: Yeah. So, first of all, I was so nervous to start medical school. I was like the most anxious I've ever been probably. But then when I got here, I just fell in love with it. So I had a really great first year I thought. I had a lot of fun learning all the anatomy, histology. I had a good time. I thought it was fun.

James: And I would say, I mean, I from the outside, I got to see Laura starting medical school. She was really nervous about starting, but as soon as she actually started, I could tell she was having a really good time. I mean, she was always excited to tell me about the things she was learning. And it didn't seem like, I mean, of course, she was studying like several hours every single day. But it didn't seem like something that she begrudged by any means. I mean, she was having a lot of fun. Like I remember she always after anatomy lab day, she'd always come home and be like, "Oh, yeah, we dissected this today. We got to see the heart, and finally we exposed the muscles." I mean, there's a lot of like excitement. So it was exciting for me I think as I got to kind of have a . . .

Dr. Chan: Kind of got to live through it, to begin with.

James: Yeah. And I kind of I think it was good for me too, because I kind of knew what the schedule would be like coming into med school. And I had been to the med school, I mean, plenty of times, just dropping her off and picking her up.

Dr. Chan: Cool. So how did it feel being on two separate years initially?

Laura: Yeah. So . . .

Dr. Chan: Because like, just for people that don't know, the first year schedule, for the most part, is mornings off, class in the afternoon. And classes, widely defined small group activities, etc., etc. Second year, class schedule's flipped, more classes, more activities in the morning and afternoons off. So like how did that work in your guys' relationship?

Laura: It's funny, because whenever we told people, we were both in medical school, they were always like, "Wow, you must never see each other. That's so sad." And we saw each other basically all day because all the med students' first and second years are in the HSEV. That's the building where we get educated and where we study. So really, I feel like we just were with each other almost all day, except for when we were in class.

James: And I would say it's, I mean, it's funny, because I mean, the way that the day looked, we would both get here, we would usually come together in the morning. So we'd get here before 8 a.m. And then whoever wasn't in class in the morning or afternoon would just study. So I would study in the morning, she would study in the afternoon.

Dr. Chan: You guys are in the library. Library was kind of your home . . .

James: Yeah, definitely.

Dr. Chan: . . . away from home because I remember seeing you a lot in the library.

James: Yeah. And we'd also I mean, at night we would be here, you know, we might go home, make dinner and then come back to the HSCB from like, 7: 00 till 10: 00 or 11: 00 some days. It just depended.

Dr. Chan: Do you guys live close by?

James: Yeah.

Laura: Yeah. The first year we lived in like the . . .

Dr. Chan: The towers?

Laura: No.

James: Not that close.

Dr. Chan: Not that close.

Laura: Yeah. And then we moved to close to downtown, close to like . . .

James: Salt Lake Regional.

Laura: Yes, Salt Lake Regional.

Dr. Chan: All right. Not too far. Okay, so when did the discussion start? Or maybe it started immediately about Laura doing something else for a year? So you guys started being the same year? Or was that a late, I mean, how did that kind of unfold?

Laura: No. So we knew about the couple's match, before we even applied to medical school. So we had always planned that I would take a year doing something else so that we would be on the same track. So I was trying to figure out what I wanted to do. Kind of the end of my first year, start of my second year, I was thinking about what I wanted to do. And I finally decided to do the unique program at University of Utah. That's the master's in bioengineering.

Dr. Chan: Okay.

Laura: So it's the Bio Innovate program.

Dr. Chan: And what were you considering? And why'd you end up on that one?

Laura: Yeah, there's a few things, a few options. So you can always take the year and just do research. You can do an MPH, you can do an MBA. So I really liked the master's in bioengineering, because I felt like it kind of fit my mindset. Like I was always interested in improving healthcare and things like that. So it really drew me in.

Dr. Chan: Was that like Bench-to-Bedside type activities? Or were these engineering classes? Or what were you doing?

Laura: Yes. So basically, it trains you on problem-based clinical innovation. So how to appropriately identify a clinical problem, how to, you know, vet the problem, make sure that it's worth going after, how to go through the FDA process for medical devices. And so, basically, I was on a team and we found a problem. We took the problem through prototyping, through the FDA, all the way to like forming a company during that year. It was really fun.

Dr. Chan: Oh, can you talk about it? Is it . . .?

Laura: Yeah.

Dr. Chan: Or what was the product? What was the device?

Laura: Yeah, yeah. So it was really fun because I was on a team with three other women. And so we went after a women's health problem. We ended up developing a new videoscopic vaginal speculum, and we just thought the pelvic exam need a ton of work.

Dr. Chan: Could use some updating.

Laura: Yes, exactly. And it was just a really fun year working on that. We took it to Bench-to-Bedside, which is the medical device competition in Utah, and we ended up winning first runner up. So we got $10,000 in seed funding for our product, and then we formed a company. We have filed an international patent on it since then. And it's going through kind of like licensing negotiations right now.

So how does that work with you continuing on with your training? I mean, do you get I mean, are you on like the board? Or how are you still connected to the company? I mean, how does that work?

Laura: So I'm not really anymore. The University of Utah has rights to that patent. And they're in charge of negotiating the licensing agreement, and then I'm moving for residency.

Dr. Chan: Foreshadowing, yes. Spoiler alert. Yes.

Laura: For me, like that project is more how I learned to do this medical device innovation. And so, for me, I'm going into dermatology. I think dermatology is just primed for medical innovation and, you know, dermatologists already personalize so much of their medicine, it just makes perfect sense.

Dr. Chan: All right, yeah. Okay, so bioengineering?

Laura: Yes.

Dr. Chan: So then you guys, you do that for a year. James is finishing out second year, and then you're finally linked. Start third year together? Is that accurate?

James: Yeah. it was really nice Because I mean, I'd always been, I wouldn't say I felt like I was behind. But I mean, like Laura, always she always like . . .

Dr. Chan: She lorded it over you, that you were an underclassman at all times.

James: No, it was just, it was really nice, because, for the first time, we were kind of going through the same things together. So rather than, like, one of us like having a fresh take on something and the other person having already been through it, we got to do a lot of things at the same time. So it was a lot of fun to kind of work through the clinical years, like third and fourth year together.

And our first rotation during June of our third year was family medicine. And we both got to go together and do rural family medicine down in southern Utah. I was in, we were both in St. George at different clinics. And I was in hurricane for part of my time too. But it was really fun because we both got to see clinical problems at the same time, like the same thing, study together for our shelf exams. It was a really fun time, I thought.

Dr. Chan: Did you actively try to have similar rotations? Or is that just happenstance you're on family medicine together?

James: It just happened. We ended up having family medicine, pediatrics, and OB-GYN at the same time, but we never were on the same teams.

Dr. Chan: And you played it cool?

Laura: Yes.

James: Yeah. I mean, I think all the [inaudible 00:14:58] Directors, I think knew that we were a couple.

Dr. Chan: Because they can kind of tell there's some sort of energy about . . .

James: We'd show up together. We'd eat each other's food.

Laura: Dr. Good specifically.

James: Yeah.

Laura: Well, and we talked . . .

Dr. Chan: We just met Dr. Good, I don't know, we just seemed to hit it off. Don't all the third years kiss each other?

Laura: We had talked about it with Dr. Stephenson, and I guess some couples try to be together and some don't want that, like people to know that they're a couple and so we were kind of like let's not try to be together.

Dr. Chan: Let's play it cool.

Laura: Yeah. Let's play it cool.

Dr. Chan: All right. Okay, so James, if I had talked to you in the first two years of med school, what were you thinking of going into? And then what changed your mind? How did you evolve to your eventual choice?

James: Okay, this is a good conversation to have. So I came into med school planning to become a physiatrist. So that's a doctorate in physical medicine and rehab. I was exposed a lot during my undergrad. I did a lot of research in motor control and motor rehabilitation. My undergrad was in exercise science. So it really fit kind of the things that I was interested in. And then I shadowed quite a bit in the different areas of PM&R, which because it's quite broad.

Dr. Chan: And let me just explain what that is to people because people they don't know too much about PM&R. So what kind of doctor is that? And what do they do?

James: So physical medicine and rehab doctor or a physiatrist, it's sometimes called, they're doctors who take care of patients who have been through like life-altering changes in function, so a spinal cord injury, a stroke, a traumatic brain injury, or other types of brain injuries, as well as acute and chronic, like musculoskeletal injuries, so polytrauma patients, once these people are stabilized and out of ICU setting, out of the hospital floor, a lot of them benefit from daily like rehab, from physical therapy, occupational therapy, speech therapy, so they come to what's called the rehab floor.

Dr. Chan: Or another facility.

James: Yeah, or another facility, yeah, it could be a standalone hospital or rehab hospital. But medically they're run by PM&R doctors. So we manage heart failure, infections, lines, you know, wounds, different surgical problems that need to be addressed by other doctors. We basically quarterback all the medical problems so that the therapist can do their thing with the patients three hours a day. And so they have to meet strict criteria to come and see us in the rehab wing. But I just like that because we get to do both the acute setting, but then we get to follow them in the outpatient setting as well.

So there's a lot of good continuity. I love the neuromuscular system. So just a lot of the medicine that I like to do. And during med school, I would say up until third year, that's what I was planning on doing. I really liked my surgery rotation and not because of the surgery, but I liked the anesthesia aspect of it. When I was on my community rotation for two weeks at Altaview I got to do like most of the intubations, because the anesthesia team there was very into medical students because they hardly get medical students there. And so I got to do a lot of intubations there. And I thought that it was really fun, immediate medicine. You get to give medicine, see the effects immediately, which is pretty rare for a lot of doctors. And so like I considered anesthesia pretty seriously during third year.

But then I finally came back and did a two-week elective in PM&R at the end of my third year. And it just kind of sealed the deal. I got to go back to the rehab unit. And it's just that's the environment that I really enjoy. It's very multidisciplinary. We get to work with like seven or eight different allied health professionals. Everyone's kind of giving their take on what the patient needs, and the patients are very involved in that process. So it just seems like good medicine, and it was what I was most interested in.

Dr. Chan: So you were the prodigal PM&R doc. You maybe left a little bit, but then you came back home.

James: Yeah, yeah. Again, I would say I'm lucky because a lot of students never see anything in PM&R during med school. It's very sub-acute. It's kind of like after the fact, you know, everything's about trauma and surgery and acute medical problems in the hospital. But we are more focused. We're kind of like the post-acute care specialists.

Dr. Chan: Okay. I like that. I learned something. That was beautiful. All right. What about you, Laura?

Laura: Yes. So I . . .

Dr. Chan: You mentioned dermatology?

Laura: Yes. So I went to med school thinking I would do pediatrics. And I just really like taking care of kids. And that has not changed since I started medical school. But then I shadowed a dermatologist kind of by happenstance. And I just thought he was a really good doctor. So I kept shadowing him and fell in love with dermatology along the way.

Dr. Chan: So is this in the first two years?

Laura: It was the kind of the end of my first year.

Dr. Chan: Okay, yeah.

Laura: So I love dermatology. I think it's perfect for me. It's a very broad field. And people think that it's not, but it is. I say that dermatologists are experts in a lot of things. And it's fun, because you can make a really broad differential with lots of organ systems. It's really nerdy, which fits me. I like knowing, you know, details of things. I like the idea of being the consult expert on something. So . . .

Dr. Chan: All these rashes have these really intricate names.

Laura: I love that. James always makes fun of me for that.

James: I do. It's a constant.

Laura: What do you say? You're like, "How many adjectives can you put in a rash?"

James: And none of the adjectives actually end up meaning anything about the diagnosis. They're all misnomers too.

Laura: They're all misnomers.

Dr. Chan: Interesting. So third year, were you tempted at all by anything else?

Laura: I was actually, yes. So I, for a minute there, thought that I was going to be a general surgeon. I loved my surgery rotation. It was kind of in the dead of winter. But I ended up loving it. And I was on I remember, bariatric, Fogart bariatric service, which was so fun. And I was like, you know, I could see myself really doing this. And so I would spend time like outside of my rotation, going to other surgeries, exploring other surgical specialties to see what I liked.

But anyway, in the end, I kind of was like, you know, they always say, if you love the OR more than anything else, then be a surgeon. And I was like, "I'm not sure that that's totally me." So I went back to dermatology.

Dr. Chan: Okay. Okay, so you have your fields picked. What is your strategy going into fourth year and interviews and residency application? Did you have a coherent strategy at the beginning? Or was it kind of ad hoc?

James: I mean, I think we kind of thought we had a good strategy. And I think it's important . . .

Dr. Chan: What was your initial strategy?

James: So we made a list of all of the PM&R programs and all of the dermatology programs, and we knew from the gate that we were . . . dermatology is more competitive than PM&R. But physical medicine and rehab is still really competitive. It's a small field. There's not a lot of . . .

Dr. Chan: All fields are competitive nowadays.

James: Yeah.

Laura: So true.

Dr. Chan: It's just a different degree of competitiveness. Yeah.

James: So the first thing we did was see all of the cities where the programs lined up, because they're both small fields. So it's not like internal medicine or surgery where you can apply to Chicago, and there's 35 different programs in one city, you know. I mean, even in the largest cities, they're still like five programs in, you know, in Chicago, New York.

Dr. Chan: So you're targeting larger Northern cities?

James: Well, we were targeting the whole nation actually. So we literally . . . I applied to 65 of the 75 PM&R programs, and you applied to . . .

Laura: I applied to 110 dermatology programs.

James: Of the 117 . . .

Dr. Chan: Dermatology clinics.

Laura: Yeah, I think there's like a 100 . . .

Dr. Chan: So if you feel comfortable in sharing, how much did that initially cost? Because we're talking about clicking those boxes, right? Like the little Amazon bin, the cart just growing.

Laura: Yeah. Well, I actually got a fraud alert from my credit card when I tried to pay that. So I was like . . .

Dr. Chan: So ballpark is $10,000?

James: Not that much.

Laura: No. So initially, it was probably $2,500 for each of us just for the ERS application.

James: And that included . . .

Dr. Chan: That's before interviews, before anything. That's the first step.

James: And I will say we did not know . . . I mean, we knew we were going to spend a lot on interviews, but we didn't know coming out of the gate that it was going to cost us several thousand dollars each just to apply. And we had to apply to prelim years too.

Dr. Chan: Well, all those programs, it takes, like, you know, to print the paper, to open up a file.

Laura: Yeah, that's what it is.

James: We can talk about the racket of all of this another day.

Laura: That's another topic.

James: It does kind of count. I'll put that on the record. It's a racket for sure.

Dr. Chan: All right. So the initial strategy, apply broadly, a lot of programs. Okay.

James: And just see what happened, because we didn't know how competitive we would be. We didn't know. I mean, it's . . .

Dr. Chan: It's the kind of same thing in med school. Like I know, there are certain key differences in the match. But one of I think the core similarities are, if you apply broadly, and then you start seeing how many interview offers you get, you get a kind of a sense of how competitive you are nationally and like what your odds are, right? So if you apply to 50 med schools and you get like 2 interview offers, like you're kind of in rough shape. But if you apply to 50 med schools and you got like 30 interview offers, you go, like, you're in really good shape, right? I would venture the same thing is true for both your fields.

Laura: Yeah, totally.

James: Definitely. That's the, yeah, that's the case.

Dr. Chan: So who started hearing first? Or you know, how did the interview offers trickle in? And then, okay, so yeah. You guys are making faces at each other trying to figure how this all unfolded.

James: I'll start off by saying, so dermatology interviews very late. And we knew that going into it.

Dr. Chan: They want to maximize anxiety.

James: Yeah. So it's hard because PM&R interviews, I mean, starting from mid-October until mid-January, but I'd say 90% of the programs interview before New Year's. So I started getting interviews almost . . . we submitted like late, late September, like the 28th or something, I think. I can't remember the exact date. And then we started getting, I started getting offers within the week for programs.

And so the interview offers, a lot of programs offer more spots than there are, or they offer more interviews than there are spots for those interviews. So you have to literally the minute you get the text, like the second you get it, you have to schedule it.

We both had instances where we missed it by a couple minutes, and we were not able to get an interview. We both had that happen. So you have to get it immediately. We both set up a separate email account and had the emails forwarded to our text messages, our phones on full ring to get the email and the text message to make sure we didn't miss it.

Dr. Chan: Wow.

James: We were both on away rotation at Northwestern when this was happening. So we were both in Chicago, and we had to like step out of rounds. And the good thing is at least my attending teams were really, they were really good about it. But you have to schedule them immediately on a phone and it's . . .

Dr. Chan: Did you have time to coordinate between the two of you? Like were you texting? Or you just okay . . .?

James: There's zero coordination.

Dr. Chan: Or you just have to like just grab that interview offer and just deal with the consequences and the flights and all the other stuff afterwards?

Laura: Yes. So the problem with having different interview seasons is I don't know where I am getting interviews yet. And James's interviews are piling in. So he actually just went on every single interview he got basically.

James: Well, that's not true. But . . .

Laura: But basically.

Dr. Chan: It feels true.

James: I went on.

Laura: You tried to.

James: I went on nine interviews before Laura had even received a second offer. She only had received one offer because most interviews for dermatology don't even come out until after Thanksgiving. And I had been on nine interviews by then.

Dr. Chan: So again, this is great. I love talking about this, because there's so much like so much going on. So James, did you feel that you were kind of like the tip of the spear, meaning that you had to be on your A game because, you know, Laura might have to . . . you know what I'm saying? You were kind of the first wave of the couple. And if you were very, very impressive, that there might be some communication where they would kind of say, "Hey, we really like this James guy. You know, let's make sure that Laura gets an interview," or did you not think like that?

James: So that was definitely my mindset. And I can say as soon as Laura even hinted that dermatology might be her target, like when she was in second year, I knew I had to be the best student I could be, the best applicant to whatever I went into because of that, just because I knew I couldn't be the one that brought down the dermatology application because it's so competitive. And I think that that definitely helped through during interview season. And we tried, we can talk about communication of when I got an offer emailing to ask that they look at my significant other's applications . . .

Dr. Chan: So you're very upfront with that?

James: Yeah. We were very forward on that.

Dr. Chan: Transparent.

James: We emailed and called every, basically every program I was offered an interview to make sure they knew, (a), that I'm couples matching and, (b), that my wife was applying to dermatology. And if they could just reach out and let them know, "Hey, this applicant's significant other hasn't been invited to our program to interview. Just so you know."

Dr. Chan: Did they respond to that? Or was there a wide spectrum of like some people will go, will be silent? Or people would acknowledge they got the email or . . .

Laura: Yeah, for the most part, I think PM&R was very friendly about it. Dermatology I . . .

Dr. Chan: "Don't tell us what to do."

Laura: I couldn't really tell, so we just did it anyway.

Dr. Chan: Okay. All right. So your interview seasons are different. You're interviewing and your interviews start coming in. And going back to the overall strategy, what started to shift? I mean, did you feel like you started saying no to certain programs? Or you're just saying yes to everything? Or and is it budget? I mean what was the budget at and did you just blow right through it?

Laura: Yes, we did. So we couldn't feasibly have a budget, honestly, because we didn't know how it was all going to play out. And we knew that we needed to go on as many interviews as possible to maximize our chances. Yes. And so we had a shared calendar, and we'd put in all of our interviews on there, so we could see each other's interviews, and more towards, you know, when things were ramping up for me, we could start canceling interviews James had where I got rejected. So that was nice.

And then it was also places I hadn't heard from where James had already interviewed, I was kind of like harassing them, like please . . .

James: In a pleasant way.

Laura: Yes, in a very pleasant way, you know, or like, and that actually worked a couple of times. So James had an interview at a couple of schools. And one of them is the place that we matched, actually, where I hadn't heard from them. And so I kept emailing them. And I said, "Hey, my significant other has an interview there. Please, can you tell me if I'm on a waitlist, even so we know if James should cancel or not?" Because it's just so expensive. And a couple of programs said, "Yes, like you are on a waitlist." And then I got off the waitlist, you know, which was awesome. So that worked a couple of times.

James: We should save the end of that story for later. But I think it is important to recognize so upfront, like the way that the calendar looked, I mean, I had two and three interviews scheduled on like many Monday . . . mostly Mondays and Fridays are the hottest interview days.

Laura: James overbooked.

James: And most of my Fridays from Thanksgiving until the middle of January had at least two interviews scheduled, most of the Mondays. So I just want to talk about the courtesy, like it's hard because you want to give like at least a week's notice.

Dr. Chan: So they can find someone else to fill the spot.

James: It's a really valuable spot. A lot of time, it's a lot of, the whole department has to interview all these people. And it's a lot of doctors' time, and obviously, you want them, you want all the applicants to get the interviews that they need. And so you don't want to hold on to it too long. But it was hard because when we were not . . . like say I had three offers, and it was a week away, and I knew which one I wanted to go to. But it was still early enough that Laura hadn't heard from any of the programs. So you have to start making these decisions like, well, which one is the most feasible for us versus which one is the one I want the most because it's the most competitive program? So it's a lot of tough decision making.

Laura: Yeah, we had to like kind of shot in the dark on a few instances.

James: And I would say our thoughts like where we thought we were going to get interviews, we were almost always wrong. Like of the three if I thought, "Oh, well, this one is probably the one that we are going to . . ."

Dr. Chan: Laura just showed me the Google Calendar. It's quite impressive. A lot of different colors.

James: It's just too much. Yeah. I mean, it's just funny because the places we thought we'd get interviews, we didn't get interviews, and the places we would never have dreamed or imagined we would get interviews, places we'd never been before with no ties at all, we got like, we got interviews. And so it's just the whole process was really random.

Laura: I remember, specifically, James had an interview in Birmingham, Alabama. And I was like there's no way Alabama would interview me. That's so random. And then he was about to cancel it and I got an interview. So like you really have no idea.

Dr. Chan: So how many total interviews did you each go on?

Laura: I got 13 offers and went on 11.

James: For dermatology.

Laura: For dermatology.

James: And for prelim year.

Laura: Yeah, so for dermatology, you have to do your intern year is not included in that. And so I had to interview for intern year separately. So I think I went on 25 interviews total for prelim.

James: Twenty-five.

Laura: Yeah. No, 17.

James: You were offered.

Laura: That's right. So I went on 17 for prelim, went on 11 for dermatology.

James: And I, let's see, I was offered 46 PM&R interviews. I went on 23, and then I was, I don't know how many prelims I was offered, but I went on 9 prelim interviews. So and I will say I mean, as an aside, most specialties don't have to do prelim views, but both of our specialties do. And they are very competitive. You don't realize it when you're applying, you're like, "Oh, I'll get an intern year. It's just an intern year. There's always open spots." But they are very competitive. You're competing with dermatology, radiation, oncology, radiology, anesthesia.

Dr. Chan: You like the programs with elective time, you know. Yeah, I know exactly what you're saying.

Laura: It's surprisingly competitive.

James: Yeah. Yeah. We were actually surprised. And we were very fortunate to have a lot of prelim interviews. But if we hadn't applied so broadly, because we were couples matching, I don't think we would have been as successful.

Dr. Chan: Do you mind sharing how much budgeted that you had to pay? Like we're talking flights?

Laura: Yes.

Dr. Chan: Rental car rentals.

James: We were talking about this.

Dr. Chan: Hotel nights, because most of these programs aren't putting you up in a hotel. Right?

Laura: No.

Dr. Chan: You're on your own.

James: I think we both had one program put us up.

Laura: Yeah. So sit down for this.

Dr. Chan: I am.

Laura: You are sitting, good. Probably $40,000 between the two of us.

Dr. Chan: American dollars?

Laura: America dollars.

Dr. Chan: Wow. Wow. Wow. Wow.

James: Yeah. And I would say that probably accounts for we both did two away rotations also, and those were not cheap. I mean, Laura went to Seattle and to Chicago, and we were together in Chicago. So I was in Chicago, and then I went to Rochester, Minnesota. So but both rotations were not cheap either. But I would say definitely the bulk of our money was spent on interviews.

Laura: Yeah. So probably $30,000 for the interviews and then $10,000 for the application process and . . .

Dr. Chan: And then did anything . . . Did you have some catastrophe, some travel plane issue or weather issue? Or did everything kind of run smoothly? Because I know that can create also havoc in the schedule and the cost?

James: We were actually, I think, pretty fortunate as far as like making our flights. Laura had one big delay when she was trying to get across the country. I think you were trying to get back to Alabama from Spokane.

Laura: Oh, yeah.

James: No, you were trying to get to . . .

Laura: Somewhere crazy.

James: It was somewhere in the South. And she was flying to Spokane connecting in Salt Lake. And the flight ended up because of weather and de-icing, it was delayed.

Laura: I basically I ran through airports constantly. But I never had a big catastrophe. So I feel very lucky.

Dr. Chan: It's just sounds so stressful.

James: Yeah, I will say we both definitely ran through a lot of airports. I mean, I know O'Hare Airport, like better than a Chicagoan. I definitely, feel that way.

Dr. Chan: All right. So you interviewed all these programs. I assume you're kind of taking notes and you're kind of forming in your mind, you know, why a certain program is better for you, a better fit than others. How did you approach your rank list? Was it kind of an ongoing discussion? Or did you like dedicate like, okay, date night, this weekend, we're going to just hash this sucker out? Like, what was your kind of approach? What kind of values did you try to like adhere to? I don't know if there was an initial strategy, so, like, what was your thought process? How'd you do that as a couple?

Laura: So I think our rank list was kind of ongoing. We had some shared notes on our phones that we could look at where we each kind of like wrote down what our individual rank lists were, and then we would go to the gym and work out and like talk about our rank list at the gym, like a lot.

James: Yeah. All the time.

Laura: So I had heard that making the request for couples can be very, what's the word? Tenuous?

James: Yeah. A lot of back and forth because . . .

Dr. Chan: Well, it can create stress on a relationship.

James: And I think we were actually pretty fortunate because I think, first and foremost, we both had a lot of really good options. And I think that's the big thing is I don't think there was a program that ended up being on a rank list that we wouldn't, that we didn't think was a good program.

Laura: Yeah.

James: So things like geography were, there were certain places we were more interested in living than others, but we were definitely okay with moving like anywhere. And obviously, strength of the program, but we were looking for also the kindest program. And I think that was something that varied more than we thought it would between programs, just in when you visit, you can just really tell the culture of a program by even how they treat their residents and things like that. Those were things that we're really interested in. And that affected like where we ranked certain programs.

Laura: Yeah, I think I valued collegiality of a program very highly. And then also, you know, the academic strength of the program overall. I think those were kind of my top two things. And I don't know, I felt like a lot of our ranks between me and James, we both liked a lot of the same programs, so it ended up being pretty easy for us to make a rank list.

Dr. Chan: Okay. So no disagreements or no program that was kind of an outlier for one of you?

James: I mean, we went back and forth, I would say. Our lists, the very top of and the very bottom, I would say they weren't big changes there. But the kind of the middle, I think we changed quite a bit over the two months that we were seriously like conversing about a lot of different programs. But I think we were pretty much in agreement by the end about where we ranked things.

Laura: There's a derm program that I really liked. It's kind of it was like a top derm program that I really liked that wasn't as strong in PM&R. And I think that was the only one that I wish had been a little bit higher, but we matched above that, so it's okay.

Dr. Chan: And this entire time going back to the, like the thank you notes or love notes, like, are you guys just like carpet bombing all these places? Like what's your strategy here? And I assume I get the sense PM&R kind of responds, but like dermatology is just kind of like radio silence.

Laura: Yeah. So I . . .

Dr. Chan: I guess what the question is, what was your communication like with the programs? As the rank list evolves and gets solidified, what were you doing to kind of share those feelings? Yeah.

Laura: I think the interview and post-interview communication culture is different between specialties. And in dermatology, I had kind of understood, you tell your number one program they're your number one, and then you don't tell any of the other programs anything really. So that was what I did. What did you do, James?

James: Yeah. And I think, yeah, the statement that the cultures are different is true. I would always . . . the coordinators are like your best friends and these interviews and before and after, because they obviously have the time to respond to things. And they're mostly very, very nice people. They are really organized. And on interview day, I would always get a sense of how much they valued thank you notes. And I had two kind of coordinators specifically that told me, "Oh, I know that the program director looks specifically to see whether you've sent thank you notes or not," which is important.

So I sent thank you notes to every single interviewer that I had whose email address I could get, and some programs don't write . . . and if they tell you specifically not to, then I didn't. And I had a few that were like that. But besides that I sent a strongly worded like letter to every single program that we were ranking, saying that I liked their program. And then for my number one, I just told them that they were my number one and the reasons why they were.

Laura: Yeah. So James had a lot more emails to send then, because dermatology, almost every program said specifically do not send thank you notes.

Dr. Chan: All right. So you submit your rank list in February. How was it from February to March? Felt good? Doubting yourself?

Laura: Yeah. I felt good. So part of it was I was off rotation in February. And after, like submitting my rank list, I was like, I felt like free. I was like, you know, this is awesome. The load's off my back. I can just hang out.

Dr. Chan: Need to work.

Laura: Yeah.

Dr. Chan: And make some money, pay back that $40,000 little gift that keeps on giving?

Laura: Definitely.

James: Yeah. Yeah, I agree. I think I was, I wouldn't say at peace, but I was content that it's out of my hands. You know, I think everyone says that. Everyone seems to echo that sentiment that even if they, thinking back, like, oh, I wish I would have changed four and five or something, at least, you know, you can't change it anymore. And it's kind of like you're letting this computer just make a decision for the rest of your life. And you can kind of just abide by that. And no, you couldn't have done anything different because, at this point, you can't. So I think the pressure was kind of off in some ways. And we knew we had a lot of good options. But we always kept telling ourselves like we could drop to the very bottom of our list.

Even if though we wanted to get, you know, one of our top five, I think we said any of our top five would have been great options, we would have been thrilled about that. We always told ourselves, we ended up having like 11 different programs that we ranked together. And even if we dropped down to the bottom one, we said, you know what? Like going into this, our most important thing was that we'd be together for training. It's still a good program. And we would be thrilled just to be able to have that.

And I think it's worth . . . we should probably talk a little bit about how we made our rank list, because the couple's ranked list, it can kind of be a mess. You connect your applications through the NRMP's portal for the match. So rather than having a list of, you know, 12 programs, you have a list of combinations of those 12. Luckily, ours were so spread out that it was kind of, we didn't have to do the A with A, A with B, B with A. They were all in the same city. We didn't have that scenario. We had one city for each set of programs. So our list was fairly short for our primary list. But we did do some like secondary and tertiary lists below the primary list. I don't know if you want to talk about that a little bit.

Laura: Yeah, just to make sure like some couples are okay with living apart a certain distance, and we kind of decided we weren't okay with that. And also, the secondary list is kind of like to make sure you at least get a prelim spot. So that was our strategy.

Dr. Chan: So the Monday of match week, was that more anxiety provoking than the Friday, or what was your feeling?

Laura: I think it was.

James: Yeah, I agree.

Dr. Chan: Because this is when you, this is where you, no, this is the time when you find out if you matched, and then Friday, you find out where you matched.

Laura: Yes.

Dr. Chan: So Monday, could be very difficult full attention.

Laura: Yeah, yeah. I was very anxious for that Monday. Just because like, you know, there's always a chance that you don't match. And especially with a couples match, we felt additional pressure. And so I was on the ICU rotation, and I was just so anxious. We were on rounds, and you get the email at 9 a.m.

Dr. Chan: Which I heard was a few minutes late this year.

James: It was a few minutes late.

Laura: It was. And so I just I was like I need to like get up and just walk out and . . .

Dr. Chan: You start coffee.

Laura: I just told my team, I was like, "I'm going to find out if I matched. If I don't come back, you know why." So I just walked out and waited for the email. And when I got it, I was just, I was so happy. I was like crying. I'm so happy that I had matched.

Dr. Chan: Where were you, James?

James: So I was off rotation in March. I'm just doing research this month. And so I actually went to Dr. Stephenson's office, because they have rooms set aside for people where you can go and you can just find out from Dr. Stephenson as soon as he finds out if you matched or not. And the reason I did that is because the way that our couples match rank list was set up, we prioritized Laura's match over mine in the secondary lists. So we had our list of us together. But then after that, we had Laura matching dermatology and me matching just intern year, just because the dermatology match is so much more competitive.

And so I wanted to get that email because the email tells you if you partially matched, that is you only got either a prelim year or maybe just an advanced position, but not a whole match or if you matched entirely. So I wanted to find out if I matched like entirely, because I, if I knew that then it also meant that Laura match because we landed one of our first 11 programs together. So I went, I just wanted to hear it from the horse's mouth like, "Okay, you're good. I'll see you on Friday." And that's what happened, right? When the emails came out, he just popped his head in and said, "You're good to go. I'll see you Friday." So it was a really good day. I ran out of the School of Medicine. I was jumping up and down all the way to my car. So it was a really good moment.

Dr. Chan: And then Friday, who was there? Both your families or . . .?

Laura: Yeah, so my parents were there, my, one of my siblings and his wife.

James: And my parents were there. And my twin brother was there as well with his girlfriend.

Dr. Chan: And had you prepared them? Because we really haven't talked about Utah. Had you prepared them for the possibility that you could be moving away?

Laura: Yes. Well, I told them, I said . . .

Dr. Chan: "I love you, but I need a break."

Laura: No, like . . .

Dr. Chan: "A physical distance break."

Laura: They were actually aware of my rank list.

Dr. Chan: Okay.

Laura: So they knew, but I told them, I was like, "No matter where we match, you have to be happy for me. That's how it works."

Dr. Chan: You were lecturing them about unconditional love?

Laura: Yes.

James: Well, I mean, I think it's important just let your loved ones know, especially for the couples match, that just landing together is a monumental feat. I mean, especially in small specialties with I mean, there's like less than 500 spots in each of our specialties. So nationally, the fact that you can both end up at the same program for training, it's really, really difficult. I mean, the numbers are not with you. And as you can see from our, from all of this, it's a lot of work. And so my parents, they didn't really know my rank list. And I didn't really go through all of the intricacies of the match with them. But they did know that there was a possibility that we wouldn't be together. And I kind of, I think the overarching theme that if we end up together, it's a win, they understood that.

So that was kind of how they went into it. But I think that they knew that we, there's a big possibility we could be leaving Utah. I should say there's only one PM&R and one derm program in Utah. It's at the University of Utah. Most states only have one or zero.

Dr. Chan: Okay. So a bunch of speeches, they cut the ribbon, and what do you guys do? Do you go get your envelopes and open it just the two of you? Do you bring it back to your families? How do you do that? Simultaneous? One goes before the other?

Laura: Yes.

Dr. Chan: Open each other's? Oh, I have so many variations of it.

Laura: Yes. So much you could do. I don't know if I fully considered all of those options. But we basically made a beeline for the table immediately, and then brought it back to our family and opened at the same time.

James: Well, and I mean, they called us all up before they cut the ribbon and there's just this mass, there's a horde of us students. We're all up there. We're like, salivating trying to . . .

Dr. Chan: You can just feel the energy.

James: Everyone's kind of like, "Oh, hey, oh, hey," you know, it's like we're exchanging pleasantries, but really, it's like, "Get out of my face. I want to get my envelope."

Laura: Yeah, I was like, I'm pretty sure one of the news outlets here took a photo of me like reaching across everyone to like grab my . . .

Dr. Chan: Throw out some elbows.

James: Yeah, I'm getting out of the way. I'm like standing straight up. My arms are up just to let her through and grab her envelope because she was not, I mean, nothing was going to stand in our way.

Dr. Chan: So where'd you match?

Laura: We matched at . . .

James: Vanderbilt.

Dr. Chan: Nashville, Tennessee.

James: Yeah.

Laura: Music City. Yes. We're so excited.

Dr. Chan: Home of white-hot barbecue. I don't know. There's all these ghost pepper barbecue.

Laura: I didn't know this actually.

James: They're like Commodores. I know that. That's about all I know. Lots of good music.

Dr. Chan: So how do you feel about it?

Laura: We're thrilled to be matched at Vanderbilt. And it's a great program for both of us. It was very high on our list. And Nashville is a really fun city.

James: So yeah, we were both super stoked. And I would reiterate, like we said, one of the things we were really interested in was matching at programs that had really collegial I think, just to borrow Laura's word, collegial programs with really friendly cultures. And I think we both noticed that at Vanderbilt immediately when we got there was. Everyone was very collegial. And for programs as highly ranked as Vanderbilt was for both of our specialties, we were really surprised by that. And so I think that's one of the reasons why it was ranked so highly was because it was really good training combined with a really, really friendly culture in both of our departments. So we were really happy about it.

Laura: Yeah.

Dr. Chan: How did your families react?

Laura: They were happy I think. I could tell that my parents were sad that I was moving away, but . . .

Dr. Chan: They're secretly hoping for like the Western U.S. kind of thing.

Laura: Yeah, exactly. But which I knew was going to be their reaction if I was moving. But they were very, very, very happy for me.

James: Yeah, my folks were really happy as well. I think that they were, they're also kind of bummed I think that we're moving, but at the same time, I think they knew going into it, they knew that, you know, medical training can take people all over. So I think . . .

Dr. Chan: You guys can always come back.

Laura: Yeah.

Dr. Chan: As attendings or for fellowships or whatever.

James: But I will say, I mean, Match Day was kind of bittersweet, because we found out we're actually not going to be in the same city for intern year.

Dr. Chan: Oh, was that also in the envelope?

James: It was in the envelope, yeah. So and that's something that's the couple's match, you can couples match into your primary training, but each, like we said, a PM&R and derm both require a prelim separate rank list for each program. So our rank one, we rank a program, and then you have to make a sub-list under that program of different intern years that you rank for that program, because they only cover years 2 through 4 of training. And so you can't couples match into those sublists. And so we knew going into it, there was a big possibility that some of the intern years might not be together.

Laura: Yeah, I feel like that's a whole other podcast, Dr. Chan, that right there.

Dr. Chan: You'll have to come back. So where did you match for your prelim year?

Laura: So I'm going to be at Providence Sacred Heart Hospital. It's in Spokane, Washington.

James: And I'm going to be actually in Nashville. So my program was categorical through PM&R, so it's a prelim year at Vanderbilt.

Dr. Chan: So I like what you said, bittersweet. So just this rush of emotions, like the main, you know, Vanderbilt, but like the first year. Yeah, thousands of miles.

James: Yeah, it was . . . And I think it was hard. Our families were, I think they knew going into also . . .

Dr. Chan: Confused.

James: Yeah.

Dr. Chan: What is it? What's going on?

James: My parents I think we're pretty confused. They're like, "Oh, well, I thought the match made it so you could be together." I'm like, "Well, yeah, that's true, but the prelim year it doesn't account for." And I think that's just one of the intricacies of the couple's match that's hard, but it's just the way that the system is set up.

Laura: Yeah. I was like it was definitely bittersweet, because I was like crying of happiness. But also I was like, oh, like, you know, it's sad that we didn't get that first year together. But I think overall, very happy.

James: Once we had some time to process, I think that it was . . . it's hard because everyone's like up jumping up and screaming like, "Oh, I'm going here. I'm going here." And we were so happy about Vanderbilt. But I think in the moment, we were kind of, like, shocked. We're like, "Oh, like, we're not going to be together. What does that mean?" You know, especially, I mean, we've just finished talking about how . . .

Dr. Chan: You've been together for the past eight years.

James: Yeah, we did the impossible by getting into the same med school in different years, you know, and there's no couples match for med school admissions. You know, it's very, you just, you both need to get into the same school. And so I think it was just we were surprised, I think. We thought that our, we knew it was an option, but it just was, it was just it caught us off guard. And I think it took us some time to process that. But we definitely, overall, are really stoked about Nashville. It's going to be really good training for us.

Dr. Chan: Are there direct flights from Nashville to Spokane?

Laura: No.

James: No. definitely not.

Dr. Chan: Laura looked into this.

Laura: It's like, I don't even know [inaudible 00:53:20].

Dr. Chan: That's only about a 30-hour drive.

Laura: Yeah, yeah.

James: Yeah.

Laura: And I don't think Spokane has direct flights to a lot of places except like Seattle.

Dr. Chan: Well, it'll go by quickly. I'm sure once you're . . . Have you gotten your call schedules, rotation schedules already?

James: They're in the works.

Dr. Chan: So then you can start looking at the weekends and the vacations, and it'll just like, like, Laura, you just showed me on your little Google Calendar, it'll be kind of like that. Okay.

Laura: It will be really interesting. I think it'll be fun. We have family too in Seattle. So it'll be fun to hang out with them a lot, and nieces and nephews in Seattle.

Dr. Chan: You guys doing all the different programs started reaching out to you.

Laura: And yeah, it's kind of . . .

Dr. Chan: Congratulating you.

Laura: Oh, my gosh, Match Day is such a crazy day because like oh, my gosh, it's so crazy. You're finding out where you going. You know, you're thrilled at where you match. You're finding out your intern year is not together. And then you're getting like bombarded with phone calls from your programs because they want to call you and congratulate you. And they're also sending me 1,000 emails of like documents to fill out.

Dr. Chan: And then like, I remember when I matched and then I got my official contract in the mail a few days later, and I've never signed, I've never made that much money before.

Laura: Yeah.

Dr. Chan: And I just remember and this contract was like a huge deal. I never signed a contract like that. Because it was like a multi, it's probably even bigger now. It was like in this like folder. I remember I had to like read through it and like, "What am I agreeing too?" It's like I have a lot of bargaining power with this. So you end up signing it. But I just remember, like, this is a big deal to sign the sucker.

Laura: I just was saying that in there. I was like, "We actually have to read contracts now because like we're employed."

Dr. Chan: So you've gotten your contracts?

Laura: Yes.

James: Yeah.

Laura: So it's really exciting to actually have a job.

James: Yeah. And I always reiterate the craziness of Match Day, like literally my phone was exploding the whole day. Both of our batteries by lunchtime for our phones were down to like 10%, because I'm getting Twitter notifications and everyone's posting their photos. And one of my good friends I met on the trail actually, he's going to be my co-resident at Vanderbilt. And we met at like three different interviews, and we really, we got along really well and he was texting me like, "Hey, we're going to be co-residents. It's going to be so great." And I'm like, I'm trying to like still process you know, like, "Oh, I'm moving to Nashville. Okay, I'm going to be in Nashville for sure. Laura's going to be in Spokane." Our families were like, "Oh, like, so what does this mean? How long is your training?" You know, it's just there's 1,000 people around you. Everyone's screaming. It's just a lot of stuff going on. It's a really, really stressful day.

Laura: It's such a crazy day. I just don't know how to explain it. Because I, yeah, I was getting texts from all my friends, Like, "Where are you going?" I'm getting tweet notifications, Instagram notifications. People are calling me for my . . .

Dr. Chan: You're trying to explain this Spokane-Vanderbilt thing.

Laura: Yes. My family's trying to talk to me. Oh, gosh, it was so crazy.

James: Well, and we had, we had some people on the phone also that were kind of calling in, like Laura's brother is a missionary in another country. And he was calling in for Match Day. And so we were trying to explain to him over the phone about it and video chat wasn't working. And it was just, I mean, it's just, I have like nine siblings, so everyone's texting me. There were just . . . you can't replicate that type of like notification overload. And maybe once I'm an attending, it'll be like every day. I don't know. But for March, when I was on rotation, it was a lot all at once. So but it was fun. It's a fun day.

Dr. Chan: Well, it sounds like you guys are, sounds like . . . well, first of all, congratulations.

James: Thanks.

Dr. Chan: I'm like really happy for you. And it just sounds like the journey is like continuing and I think you're going to have more stories, and I'm just it's just so cool that like I think Vanderbilt is a great program, Spokane is a great program.

And hopefully, you guys end up back in Utah one day, because we can really use you as physicians, but then I know statistically where you do residency you're more likely to stay in practice. I don't know. We'll have to see. Do you guys have any family in the South in Tennessee or . . .?

James: No, the closest we have is my brother lives in D.C., like the D.C. area of Virginia. So that's, we'll be a lot closer to him.

Dr. Chan: It's only an eight-hour car ride.

James: Most of our family is here I would say.

Laura: And my one of my brothers is applying to law school. So we'll see where he gets in. He did apply to Vanderbilt, which I think would be so fun if he got in there.

Dr. Chan: Cool.

Laura: Yeah.

Dr. Chan: Well, we'll have to have you guys come back and just have an update. But I'm just so excited for you guys. This is so amazing. So good.

Laura: So exciting. I'm just thrilled like, finally, being a real doctor and doing what you want to do is just kind of like indescribable.

James: Yeah, it's just really exciting. I think you work, you spend years and years and years of your life kind of thinking about what this is going to be like, and then it actually happens. And you're like, "Oh, I have a contract. I have a job. My first doctor job." And of course, it's more training, but it's so exciting just to think that you're going to be in charge of patients and you're going to get to take care of them and kind of . . .

Dr. Chan: You're going to have an MD after your name now.

James: Yeah, yeah. It's . . .

Dr. Chan: When you write orders, like people do it, you know like, it means something.

James: It's really exciting. So I mean, we're really thrilled to be moving, to be doing our, the next step of our training, next step of our career and the next step of our life really, you know. We're looking at where we're going to live and you know, doing . . .

Dr. Chan: Have you already gone out to the different cities to scout out apartments?

James: We're going to do that.

Dr. Chan: Can you afford a house with two residents salaries in Nashville?

James: Oh, yeah, we're looking at houses this weekend actually. We're flying out.

Dr. Chan: Exciting.

Laura: So exciting.

James: Yeah, super stoked.

Dr. Chan: All right. Well, thanks, James, thanks, Laura.

James: Thank you.

Laura: Thanks so much.

Announcer: Thanks for listening to "Talking Admissions and Med Student Life" with Dr. Benjamin Chan, the ultimate resource to help you on your journey to and through medical school, a production of the Scope Health Sciences Radio online at thescoperadio.com

Interviewer: Clinical guidance statements on treatment of blood clots or venous thromboembolism, up next on The Scope.

Announcer: Examining the latest research and telling you about the latest breakthroughs. The Science and Research Show is on The Scope.

Interviewer: I'm talking with Dr. Dan Witt, Clinical Professor of Pharmacotherapy at the University of Utah. He's one of a group of leading experts assembled by the Anticoagulation Forum to generate a series of clinical guidance statements on treatment of blood clots or venous thromboembolism. Doctor Witt, why now?

Dr. Witt: So the Anticoagulation Forum is a professional organization that is comprised mostly of front-lying anticoagulation providers. So these would be pharmacists, nurses, nurse practitioners, physician's assistants and physicians who spend most of their time working with patients who are taking blood-thinning medications or anticoagulants for treatment or prevention of blood clots.

The Anticoagulation Forum was interested in producing this document for a couple of reasons. One is that there have traditionally been guidelines produced by a group called the American College of Chest Physicians. Recently, it was rumored that maybe those weren't going to be coming out on such a regular basis. So one attempt was to try to fill a void that was going to be created by not having the regular release of these guidelines coming out.

The second one was that the evidence-based guidelines, like the American College of Chest Physicians puts out, sometimes don't resonate with frontline providers as much because they are so heavily based on what the evidence says that sometimes they can't make concrete statements about things that providers caring for patients really wonder about. So there has to blend of sort of expert advice that isn't necessarily backed up 100% by the evidence and also relying on evidence as well.

So what the Anticoagulation Forum was trying to do is provide a series of documents that really capitalized on the expertise of the people that were writing the chapters, but at the same time keeping at least one foot in that evidence-based medicine realm.

Interviewer: On the first hearing, it might sound like giving advice that is not based on evidence might sound a little scary. But you gave me an example that illustrates that idea very well.

Dr. Witt: Yeah, so one example of that was that when patients begin taking these blood-thinning medications, they have dramatic effects on their lifestyle. For some of the medicines, even the food that they eat can interact with these medicines and they have to be careful of the activities that they're engaging in. There are just a lot that you have to be aware of.

And so providing a lot of education up front is something that anticoagulation providers just do as a course of business. The evidence-based guidelines went out and tried to find evidence, studies in the literature, that would back that up and say, "Well, education improved outcomes. So reduced the risk of bleed, reduced the risk of blood clots, reduced the risk of death."

And you can imagine that those kinds of studies would be very difficult to do. So there wasn't any "evidence" to substantiate that. And so the guideline committee is then sort of faced with this decision to say either nothing or to accurately say what the evidence says, that there is no evidence to support that this is beneficial. So you really can't make a recommendation and say, "We don't recommend that you educate your patients about that."

And so it's situations like that where it makes sense that a course of action would be warranted, but you can't back it up with "evidence."

Interviewer: Right, and also based on the collective experience of your experts, you can make some of those recommendations.

Dr. Witt: Absolutely.

Interviewer: It seems like these statements, a lot of them are just centered on very practical situations. "This is what I see with my patient. How do I go about evaluating what to do next?"

Dr. Witt: That is right. Each of the panels as they got together, they first came up with a list of about 10 or so questions that they felt like, "Well, here are the common things that we see coming up when we're managing patients." And so then, they worked off of that list of questions to design the guidance statements. So I think it was a real practical, everyday sort of helpful way to approach the recommendations.

Interviewer: And maybe a little different than what's been done before?

Dr. Witt: Yeah, I think it is. We just learned also that the American College of Chest Physicians has published some updated guidelines on venous thromboembolism and those are extremely helpful. But I think the Anticoagulation Forum's documents stand on their own as well because they take a slightly different take on it. And I think that using the two documents complementary together can really provide clinicians with the information that they need to know to take good care of the patients.

Interviewer: You know, it seems like one of the things that are changing in managing venous thromboembolism is the treatment. Is that part of what these guidelines are about?

Dr. Witt: Yeah, that's a great question. And up until 2012, there was really only one option for the long-term treatment of venous thromboembolism, an oral medication, and that was warfarin or Coumadin.

And warfarin is sort of an interesting drug. It got its start as rat poison. And so many people still know it was used as rat poison and as they begin to take it, they'll often ask you, "Well, what is this medicine that I'm taking?"

Well, it's a very effective medicine, but it's a difficult medicine to manage because the dose is different for every patient. And then, Warfarin can be affected by hundreds and hundreds of different drugs. The food that you eat in your diet can affect how the drug works. And so, it really needs to be managed carefully.

And so, in 2012, the first of a series of new drugs called direct oral anticoagulants came out that produce the same effect of warfarin but don't require the same type of intensive monitoring that is required with warfarin therapy.

And so practitioners are now trying to figure out, "Well, how do I incorporate these new treatment options into the management of the patients that I'm seeing with venous thromboembolism?" And that was one of the things that these guideline statements were really intended to address.

Interviewer: And so what is your hope in getting this information out there?

Dr. Witt: My hope, and I think the hope of the people who were behind this project, is to get information that's practical and usable at the bedside into the hands of the people that are taking care of these patients. We tried to make it so that it was easier to read. The information is written in a very straightforward manner. We tried to summarize all the recommendations so that they're easy to find. Our hope is that it just elevates the care that patients that are requiring these medications would receive. And that will, in turn, lead to better outcomes.

Interviewer: Where should someone go to find out more?

Dr. Witt: One of the things that I think is great about these guidelines is they have been published in the Journal of Thrombosis and Thrombolysis and they are open access. So if you go to the journal's web page, you can actually click on the journal edition and any of those articles can be accessed and downloaded for free.

Announcer: Interesting, informative and all in the name of better health. This is The Scope Health Sciences Radio.